Occupational Health & Safety Section
American Public Health Association

James P. Keogh Memorial Scholarship Fund, 2005

UNION REPRESENATATIVE APPLICATION

The Occupational Health and Safety Section will be awarding scholarships that include registration for the 2005 APHA Annual Meeting, (November 5 - 9, 2005, New Orleans, LA), a one-year membership in APHA and $300.00 for conference expenses. We hope to strengthen the participation of students and union representatives in APHA and our section. We recognize that we need the involvement of workers and new health & safety professionals to make our workplaces & communities healthy and safe.

AWARD:

The value of each award is $500.00. The Section will directly pay the annual meeting fee & one-year membership to APHA with primary membership in the Occupational Health & Safety Section. Each awardee will then receive $300.00 that can be used to cover transportation, lodging, and meals. Awardees will be responsible for providing the remainder of funds necessary to cover these expenses. At the Annual Meeting we will pair each awardee with a section member with similar interests.

ELIGIBILITY REQUIREMENTS:

Union Representatives:

An OHS Section member must apply on behalf of a Union Representative who has been active in health and safety. We would like to give scholarships to local union officers, health and safety committee members, shop stewards, district-level officers and representatives. These awards are NOT intended for international union health and safety staff.

Please submit your application (by regular or email) by July 31, 2005 to:

Karen B. Mulloy
MSC 10 5550, 1 University of New Mexico
Albuquerque, NM 87131-0001
Telephone: (505) 272-4027
Email: kmulloy@salud.unm.edu
(Email preferred.)

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THIS APPLICATION FORM CAN BE REPRODUCED!
Occupational Health & Safety Section
American Public Health Association
James P. Keogh Memorial Scholarship Fund Application:

SECTION MEMBER APPLYING FOR UNION REPRESENTATIVE

Please print neatly or type YOUR (section member):

Name: _________________________________________________________________

Street Address: ________________________________________________________

___________________________________________________________

City, State, Zip __________________________________________________________

Telephone: Day (____)_________________________________________________

Evening (____)____________________________________________________

Fax (___)_________________________________________________________

Email __________________________________________________________

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Please complete for the Union Representative you are sponsoring:

Name: ______________________________________________________________

Union Name (with local,district#) __________________________________________

Union Street Address _________________________________________________

Union City, State, Zip __________________________________________________

Telephone Number: (Please indicate home or work) __________________________

Position within Union (member, steward, officer, health & safety committee
member, etc.) _________________________________________________________

Optional: Sex: _______________ Ethnic Background: _________________________

Section member should answer the following questions about the Union Representative. (You can add additional pages if you need to, but a concise response is welcomed.)

1). Please briefly explain his/her current involvement in occupational health & safety activities.

2) What tools or strategies have she/he successfully used in health & safety work?

3). Please briefly explain your work experience with the nominated Union Representative